Garnering Partnerships to Bridge Gaps Among Mental Health, Health Care, and Public Health

Integrating mental health and public health chronic disease programs requires partnerships at all government levels. Four examples illustrate this approach: 1) a federal partnership to implement mental health and mental illness modules in the Behavioral Risk Factor Surveillance System; 2) a state partnership to improve diabetes health outcomes for people with mental illness; 3) a community-level example of a partnership with local aging and disability agencies to modify a home health service to reduce depression and improve quality of life among isolated, chronically ill seniors; and 4) a second community-level example of a partnership to promote depression screening and management and secure coverage in primary care settings. Integration of mental health and chronic disease public health programs is a challenging but essential and achievable task in protecting Americans' health.


Introduction
In 1999, Mental Health: A Report of the Surgeon General challenged the public health community to define health as a state of complete physical, mental, and social well-being. The report also challenged public health and social service agencies, health care systems, policy makers, communities, and the public to take action to promote mental health for all Americans (1). Integrating mental health and public health programs to prevent chronic disease will require initiating, developing, strengthening, and sustaining public health partnerships with mental health programs at the local, state, and national levels to leverage the strengths and resources of partners and work on common goals (2,3).
Crossing the Quality Chasm: A New Health System for the 21st Century (4) and Improving the Quality of Health Care for Mental and Substance-Use Conditions (5) describe how the health system could be reinvented to foster innovation, promote prevention and self-care activities, and develop team-based approaches to improve the delivery of care. Similarly, the goal of a transformed public health system is to integrate mental health and physical health so that policies and programs are "person-centered," or more holistic. In this article, we describe examples of partnership projects that appear promising for incorporating mental health promotion into public health promotion. We draw these examples from the national, state, and local or community levels (6,7) (Table). Successful partnerships include participation by representatives from public health programs related to chronic disease prevention and control, mental health and primary care providers, and community members, including mental health advocates. Additional stakeholders include academic institutions, substance abuse counselors, faith-based communities, and business, civic, and political leadership.

Partnership Projects
On the national level, a federal partnership between the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Centers for Disease Control and Prevention (CDC) is developing and implementing mental health and mental illness modules in the Behavioral Risk Factor Surveillance System (BRFSS). These modules provide data on state-level estimates of mental health (8,9) and assess the associations of mental health and mental illness to chronic diseases and health risk behaviors (10). On the state level, partnerships have been established among multiple offices and divisions within the Maine Department of Health and Human Services, an academic center, and stakeholder groups to integrate health issues into a mental health system designed to improve diabetes health outcomes for people with serious mental illness.
On the community level, a Prevention Research Center has partnered with local aging and disability agencies and other community organizations in Seattle/King County, Washington, to modify an existing home health service to reduce depression and improve the quality of life among socially isolated, chronically ill seniors (6). The second community-level example is a partnership between the New York City Department of Health and Mental Hygiene, municipal hospitals, and the New York Business Group on Health to promote depression screening and management as standard practice and to secure coverage for this service in all primary care settings in New York City (7).
The elements necessary to bring about change have been well described and are applicable to an effort to integrate mental health and public health policy and programming (11): 1. Make the case for the need for change through epidemiologic surveillance partnership efforts. Such efforts should coordinate the collection, analysis, and dissemination of data on the interrelationships between mental illness, health risk behaviors, and chronic diseases and their effect on the health of specific populations. For example, those who initiated the Maine project produced and disseminated BRFSS and Medicaid data on the interactions among mental illness, health risk, and chronic disease and their effect on health outcomes as well as use and cost of services. These reports gained support from senior administrators from state Medicaid, mental health, and public health agencies to promote integration of mental and physical health. Critical to the success of this effort were state-level data that showed partners how addressing mental health can advance their core mission and objectives. 2. Recruit a "champion" at every level. Change requires motivation from the top, but at least 1 champion is needed at each level to initiate, implement, and sustain change.

Sustainability
The partnerships described here have emerged only in the last 5 years and are as yet fledging efforts. The next phase requires development of strategies for maintaining and expanding these promising efforts. Multiple studies point to factors that can improve sustainability (12)(13)(14)(15).
Steps that advance sustainability include participatory engagement with stakeholders, where all stakeholders contribute collaboratively to a strategic planning process. Partnerships that maintain healthy relationships -high levels of trust, reciprocity, and respect -have better chances of being sustainable (12,13).
Also needed for sustainability is institutional support, where the integration of mental health and health issues is embedded throughout the organization, for example, in strategic planning, messaging, standards, accountability, organizational charts, job descriptions, and contract language. Projects aligned with existing institutional priorities or leading to institutional policy changes are more likely to be sustained.
Process and outcomes measures that can demonstrate positive benefits relevant to each of the partners increase the likelihood that the programs will be sustained (13). Projects are also more likely to be replicated if there is broad dissemination of outcome data tailored to the interests of each of the stakeholders. For partnerships promoting integration, evaluation activities should address personal-level outcomes across both mental and physical health, with the ultimate goal of demonstrating shared benefits.
Programs that have a "train-the-trainer" component are more sustainable than are those without training components. Trained staff members continue to provide program benefits and consistency (12). The development of sustainable training programs should target all partners, including workforce, consumers, and community leaders, and should address both health and mental health competencies.
Partnerships that invest resources for maintenance and recurring costs are more likely to be sustained (12)(13)(14). This investment may involve reallocation of funds or personnel, pooled funding from multiple partners, or giving permission in existing public or mental health funding streams or block grants to create mental health or health deliverables. It may also involve support for parity legislation, advocacy with employers who pay for health insurance, and adopting rules regarding changes in reimbursement to support integration of mental health in primary care sites.

Conclusions
Integration of mental health and chronic disease public health programs is a challenging but essential task in protecting Americans' health. The examples in this article illustrate the role of partnership in achieving this goal. Especially in times of limited resources, partnerships can capitalize on existing programs and develop new ideas that make the most of smaller budgets. Synergistic integration of activities for mental and public health will be more effective than individual stakeholder efforts.